The myth of the menopause link

by Carolyn Thomas

We know that women’s heart disease rates seem to take a big jump as we get older. For decades, early studies have reported, for example, that our post-menopausal cardiac event incidence rates are more than double those in pre-menopausal years.* And even more recent studies seem to target menopause as the likely culprit in explaining these stats; women who go into early menopause (before their 46th birthday) are twice as likely to suffer from coronary heart disease and stroke, according to Johns Hopkins-led research published in the October issue of the journal Menopause.**

So imagine the fuss when Vancouver’s Dr. Jerilynn Prior, a professor of Endocrinology and Metabolism at the University of British Columbia and also scientific director of the Centre for Menstrual Cycle and Ovulation Research, declared:

“It is a myth that estrogen deficiency associated with menopause causes heart disease in women.”

Here’s how she further elaborated this claim in an article about women’s risks for cardiovascular disease:  

“The reasoning behind this notion goes like this – young women have lots of estrogen and don’t get heart attacks. Older menopausal women are ‘estrogen deficient’ and get heart attacks. Therefore, lack of estrogen causes women’s heart disease.

“But that is like saying that headache is an aspirin-deficiency disease!”

And Dr. Prior writes that sound research – randomized double-blind placebo-controlled trials – has proven that estrogen treatment does not prevent heart disease, and therefore that “estrogen deficiency” is not a risk factor. Yet the myth persists.

One reason for this persistent myth, she observes, is cultural:

“We fundamentally believe women are somehow lacking (the anatomy and physiology of men—thank goodness) or that women are weak or ill.

“Pharmaceutical companies, some specialist physicians, and those dominant in our culture appear to gain power by treating women’s ‘deficiencies’ – often with estrogen.”

Is there any evidence at all for this estrogen deficiency myth?

Dr. Prior explains that large observational studies, including some of the data from longitudinal population-based studies like the Framingham Heart Study, have shown that women taking estrogen had fewer heart attacks than did women not taking so-called hormone “replacement” therapy.

But as Dr. Prior adds:

“We knew, even many years ago, that the women who take estrogen treatment differ in heart-protective ways from the women who don’t because they are more likely:

• to have a personal physician
• to be well-educated
• to exercise regularly
• to be non-smokers
• to be of normal weight
• to be without diabetes or high blood pressure”

In fact, the largest and best-controlled trial that tested whether hormone therapy prevented heart disease was actually stopped three years earlier than anticipated back in July 2002.  Researchers examining how hormone therapy affected heart disease concluded early on during the trial that estrogen supplements did not reduce the risk of heart attack in postmenopausal women, but worse, it actually significantly increased the risk of stroke.

It was called the Women’s Heath Initiative study, and it included over 16,600 healthy menopausal women without symptoms. But researchers found that hormone therapy not only increased rise of stroke (by 41%), but it also  increased breast cancer significantly (by 26% over placebo) and caused higher rates of heart attacks (29%) and blood clots (211%). By the way, Dr. Prior says that it’s also important to remember that both the Estrogen-Progestin and the Estrogen-only arms of the Women’s Health Initiative trials showed higher risks for stroke with hormone treatment compared with controls.

“The results of the Women’s Health Initiative require that society no longer view menopausal women as ‘estrogen deficient’ and therefore needing ‘estrogen replacement.’ Menopause is as normal for women as a menstrual period.”

And Dr. Prior particularly slammed Canada’s Heart and Stroke Foundation’s TV and print ad called Death Loves Menopause for perpetuating this myth of the menopause link. The ad, part of the Foundation’s successful “Make Death Wait” fundraising and awareness campaign in 2011, reads:

“Death loves menopause. He loves that menopause makes women more vulnerable to heart disease and stroke. And that women are far more likely to die of a heart attack. Most of all, he loves that heart disease and stroke is the #1 killer of women. Please donate, and make death wait.”

Dr. Barbara Mintzes is an epidemiologist who also teaches at the University of British Columbia in Vancouver. She calls this Heart and Stroke Foundation ad “misleading and inaccurate”

“There is no sudden shift in the rate of heart disease post- versus pre-menopause (or around age 50), as would be expected if menopause was a major risk factor for heart disease. As women age, our risks of heart disease gradually increase, similarly to aging in men.”

Laura Wershler writes about sexual, reproductive and women’s health issues for The Society for Menstrual Cycle Research. In her Troy Media piece on this subject, she reminded us:

“In 2011, the American Heart Association issued the Effectiveness-Based Guidelines for the Prevention of Cardiovascular Disease in Women. These guidelines present a long list of risk factors such as obesity, poor diet, physical inactivity, high cholesterol, hypertension and diabetes.

“Menopause is not included as a risk factor.”

Even back in the heyday of hormone therapy, when almost all doctors believed taking estrogen would prevent heart disease and dementia, the majority of women who entered menopause naturally did not take hormone therapy, and those who did often went off it within a year because they didn’t like the side effects.

Now even fewer women take hormones because doctors know much more about the potential dangers, which include an increased risk of significant cardiovascular problems, breast cancer, etc.

The decision is different for every woman.

If you’re entering menopause very early because of an illness or surgery, your doctor may advise you to take hormones until you reach the age of natural menopause.

Women who enter menopause naturally but experience debilitating hot flashes may want to talk to their doctors to see whether they are good candidates for hormone therapy based on their medical history. If you decide to take hormones, the current advice is to take the lowest effective dose for the shortest possible time.

Both the FDA and the American Heart Association now suggest that hormone therapy to address common menopause symptoms should only be used in the short term; long-term use is discouraged because of the increased risk of stroke, heart attack and breast cancer. 

♥ Image via RLS

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* “Menopause & Coronary Heart Disease.” Gordon T et al. Annals of Internal Medicine [1978, 89(2):157-161]

** “Early menopause predicts future coronary heart disease and stroke: the Multi-Ethnic Study of Atherosclerosis.” Wellons M et al. Menopause. 2012 Oct;19(10):1081-7.

See also:

• When I’m 64: aging and women’s heart disease
• Do low iron stores protect women from heart attacks?
• Women live longer – but not healthier – lives than men
• Why are gynecologists still prescribing HRT despite lnown risks?
• The haunting of medical journals: how ghostwriting sold hormone replacement therapy